Washington County Tennessee Sheriff s Office Ed Graybeal, Sheriff Employment Application Packet PLEASE READ CAREFULLY AND ANSWER ALL QUESTIONS COMPLETELY. INCLUDE A COPY OF YOUR DRIVER S LICENSE, BIRTH CERTIFICATE AND HIGH SCHOOL DIPLOMA (OR EQUIVALENT) WHEN SUBMITTING YOUR COMPLETED APPLICATION. Name Last First Middle Position Applied For Date of Application Date Available Telephone ( ) 1
NOTICE TO APPLICANTS The Washington County Sheriff s Office is an Equal Opportunity Employer dedicated to a policy of non-discrimination in employment upon any basis, including race, color, creed, religion, age, sex, national origin, military status, or the presence of any non-job related condition or handicap. In reading and answering the following questions, please keep in mind that none of the questions are intended to imply any limitations, legal preference, or discrimination based upon any non-job related information. This application will be given complete consideration, but its receipt does not imply that the applicant will be employed. Minimum qualifications for entry-level employment with the Washington County Sheriff s Office are as follows: 1. Complete and submit the Washington County Sheriff s Office application. 2. AGE: Eighteen (18) for civilian positions Twenty-one (21) for Law Enforcement positions. 3. Be a citizen of the United States, and either a resident of Washington County or agree to move to same within six months of employment. 4. Not have been convicted of a felony or a misdemeanor involving Moral Turpitude as the term is defined by law, and not have been released or discharged under any other than honorable conditions from any of the armed forces of the United States. If applicant has been in the armed forces, a copy of his/her DD-214 must be furnished. 5. Have passed a physical/medical examination by a licensed physician. 6. Have good moral character as determined by a thorough background investigation conducted by the office. 7. Hold a valid Tennessee motor vehicle operators license and be able to operate a motor vehicle with no mechanical adjustments to standard equipment. 8. Be free of all apparent mental disorders as described in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III) of the American Psychiatric Association. Applicants must be certified as meeting these criteria by a qualified professional in the psychiatric or psychological fields. 9. Be a high school graduate or possess equivalency. 11. Complete two oral interviews. 11. Submit to a writing skills test which will be reviewed for legibility, punctuation, neatness and ability to narrate in writing. 2
PERSONAL INQUIRY WAIVER When presented with a copy of this Waiver I respectfully request and authorize you to furnish the Washington County Sheriff s Office any and all information that you may have concerning me, my work record, school record, my reputation, my financial and credit status. Please include any and all medical, physical records or reports, including all information of a confidential or privileged nature, and Photostats of same, if required. This information is to be used to assist the Washington County Sheriff s Office in determining my qualifications and fitness for the position I am seeking with the Washington County Sheriff s Office. I hereby release you, your organization or others from any liability or damage which may result from furnishing the information requested above. Applicant s Signature Date,, Address City State Zip STATE OF TENNESSEE) COUNTY OF WASHINGTON) AN AFFIDAVIT ACKNOWLEDGMENT KNOWN ALL MEN BY THESE PRESENTS that on the day of, 20, personally appeared before me the undersigned authority and being duly sworn, did acknowledge that he had voluntarily executed the above instrument for the purposes therein express. SIGNATURE OF APPLICANT Sworn to and subscribed before me the day of, 20 MY COMMISSION EXPIRES. NOTARY PUBLIC IN AND FOR WASHINGTON COUNTY, TENNESSEE 3
GENERAL INFORMATION ANSWER ALL QUESTIONS - PLEASE PRINT OR TYPE Name Last First Middle Position Applied For No.: Date of Application Date Available Is there any additional information relative to a change of name or use of another name necessary for us to check your work history or educational achievements? Please explain Soc. Sec. No. Driver s Lic. No. State Present Mailing Address Street and No. City State Zip Telephone ( ) ( ) Home (Where Message May Be Left) If less than one year at present address please provide previous address Street and No. City State Zip REFERENCES List three persons who are not related to you and who have knowledge of your qualifications for the position(s) for which you are applying, such as former co-workers, teachers, etc. Do not repeat names of supervisors listed under Work History. Do not list the name of your minister or religious leader. Full Name Years Known Occupation Address Phone 4
EDUCATION Circle Highest Grade Completed 1 2 3 4 5 6 7 8 9 10 11 12 High School Graduate? Yes No Vocational School? Yes No G.E.D. Certificate? Yes No Name/Location From/To Credit/Hours Field of Study Degree High School Vocational School College or University Graduate School WORK HISTORY Describe your work history below beginning with your current or most recent job. Include volunteer experience. If you worked for the same employer, but at various times held different jobs, describe each separately. Describe in detail the specific duties, beginning with your primary duties. Attach additional sheets if necessary. A resume may be attached only as additional information. Indicate the number and types of employees under your supervision. Emphasize work you feel relates to the job for which you are applying. Failure to give complete and detailed information regarding each job you held may result in your disqualification. Current or Last Employer Address Official Job Title Supervisor/Phone Number From(Month/Year) To(Month/Year) $ Per /$ Per Hours Per Week Starting/Ending Salary Reason for Leaving Contact Person Detail of Duties 5
ADDITIONAL WORK HISTORY Current or Last Employer Address Official Job Title Supervisor/Phone Number From (Month/Year) To(Month/Year) $ Per /$ Per Hours per Week Standing/Ending Salary Reason for Leaving Contact Person Detail of Duties Current or Last Employer Address Official Job Title Supervisor/Phone Number From (Month/Year) To(Month/Year) $ Per /$ Per Hours per Week Standing/Ending Salary Reason for Leaving Contact Person Detail of Duties Current or Last Employer Address Official Job Title Supervisor/Phone Number From (Month/Year) To(Month/Year) $ Per /$ Per Hours per Week Standing/Ending Salary Reason for Leaving Contact Person Detail of Duties Current or Last Employer Address Official Job Title Supervisor/Phone Number From (Month/Year) To(Month/Year) $ Per /$ Per Hours per Week Standing/Ending Salary Reason for Leaving Contact Person Detail of Duties 6
PRE-EMPLOYMENT STANDARDS FORM I,, do hereby affirm that responses to the questions and statements below are true and correct. 1. Are you 21 years of age or older? Yes No 2. Are you a high school graduate or do you hold a G.E.D. certificate? Yes No 3. Are you a U.S. Citizen? Yes No 4. Have you ever been convicted of a felony? Yes No 5. Have you ever been convicted of a misdemeanor or federal or state laws or municipal ordinances relating to any of the following: If so, when and where? A. Force? Yes No B. Violence? Yes No C. Theft? Yes No D. Dishonesty? Yes No E. Gambling? Yes No F. Liquor Laws? Yes No G. Controlled Substance (Drugs)? Yes No 6. Were you released from the Armed Forces with an Honorable discharge? Yes No Not Applicable Please attach most current copy of DD-214 if applicable. 7. I am in good physical condition and will submit to a physical examination. Yes No 8. I authorize the Washington County Sheriff s Office to conduct a thorough background check into my past. Yes No 9. I am free from all apparent mental disorders and will submit to state-required psychological testing. Yes No 10. I agree to be finger-printed as required by state law. Yes No Signature Date 7
Self-Declaration of Sexual Abuse/Sexual Harassment Check One: Applicant Employee Unescorted I hereby certify that, to the best of my knowledge and belief, all of the information I provide in this form is true, complete and made in good faith. I understand that false and fraudulent information provided herein may disqualify me from further consideration for employment and, if employed, may result in termination of employment if discovered, at a later date. 1. Have you ever engaged in sexual abuse in a prison, jail, lockup, community confinement facility, juvenile facility, or other institution (as defined in 42 U.S.C. 1997)? Yes No 2. Have you ever been convicted of engaging or attempting to engage in sexual activity in the community facilitated by force, overt or implied threats of force, or coercion, or if the victim did not consent or was unable to consent or refuse? Yes No 3. Have you ever been civilly or administratively adjudicated to have engaged in inappropriate sexual activity, sexual abuse, or sexual harassment? Yes No By my signature below, I certify I understand my continuing affirmative duty to disclose any change in my reporting status as indicated above. I further understand that any material omissions regarding such misconduct, or providing materially false information, shall be grounds for termination. Full Printed Name: (First) (Middle) (Last) Signature: Date: Reviewed by: (WCSO Representative) Date: 8
IMPORTANT PLEASE READ CAREFULLY AND INITIAL EACH PARAGRAPH BEFORE SIGNING By my signature and initials placed below, I affirm that the information provided in this employment application (and accompanying resume, if any) is true and complete, and I understand that any false of information or significant omissions may disqualify me from further consideration for employment and may be justification for my dismissal from employment, if discovered at a later date. I authorize the Investigation of all statements contained in this application (and accompanying resume, if any). I authorize the Washington County Sheriff s Office to contact my present employer (unless otherwise noted in this application form), past employers, and listed references. I understand that the Sheriff s Office any request an Investigative consumer reporting agency that includes information as to my character, general reputation, personal characteristics, and mode of living. I understand that the Investigative consumer report may involve personal interviews with my neighbors, friends, relatives, and former employers, schools and others. I understand that under the Federal Fair Credit Reporting Act I have the right to make a written request to the Sheriff s Office within a reasonable time, for the disclosure of the name and address of the consumer reporting agency so that I may obtain a complete disclosure of the nature and scope of the Investigation. I authorize any person, school, current employer (except as previously noted), past employer(s) and organizations named in this application form (and accompanying resume, if any) to provide the Sheriff s Office with relevant Information and opinion that may be useful to the Sheriff s Office in making a hiring a decision, and I release such persons and organizations from any legal liability in making such statements. I understand that the elements of the selection process for the Washington County Sheriff s Office may include, but not be limited to, a written examination, a psychological evaluation, a polygraph examination, a thorough criminal and moral background investigation, a medical/physical examination (including drug screen) and oral interviews, and I consent to the release to the Sheriff s Office of any and all information from these examinations as may be deemed necessary by the Sheriff s Office in judging my capability to do the work for which I am applying. I understand that it is the policy of the Washington County Sheriff s Office to maintain all applications as active for a period of six months or until I receive notification of disqualification. After the six month period, if I am not appointed to probationary status I will be allowed to reapply. If I have been disqualified for a reason which assures disqualification in the future (criminal background, medical, etc.) I will not be allowed to reapply. I understand that this application does not by itself create a contract of employment. I understand and agree that if hired, my employment is for no definite period of time, and may, regardless of the date of payment of my wages or salary, be terminated at any time, I understand that no person is authorized to change of the terms mentioned in this employment application form. SIGNED DATE Sworn to and subscribe before me the day of, 20. NOTARY PUBLIC MY COMMISSION EXPIRES. THIS APPLICATION WILL REMAIN ACTIVE FOR SIX MONTHS. THANK YOU FOR YOUR INTEREST IN EMPLOYMENT WITH THE WASHINGTON COUNTY SHERIFF S Office. 9
APPLICANT FLOW DATA FORM The Washington County Sheriff s Office is committed to equal opportunity, non-discrimination, and affirmative action. This commitment is realized through our Affirmative Action Plan. This plan and legal responsibilities to equal employment opportunity require reports of job applicants by race/ethnic categories, sex, handicap, and status as a disabled or a Vietnam era Veteran. The information contained herein will be used for statistical purposes only. Position Applied For: Sex Male Female Are you an United States citizen? Yes No Race White Black Hispanic Other American Indian/Alaska Native Asian/Pacific Islander Do you have a physical handicap or disability which would require reasonable accommodation? Yes No Have you ever served in the Armed Forces? Yes Entrance date: No Discharge Date: How were you referred to the Washington County Sheriff s Office? 1. Newspaper 2. College Placement 3. Employment Agency 4. State Employment Office 5. Community Agent 6. Employee Referral 7. Walk-in 8. Former Employee 9. Other (Specify) DEPARTMENTAL USE ONLY No.: EEO/Job Group: 1. Employed 2. Applicant declined position offered 3. No suitable position available 4. Other Candidate more closely met the job qualifications 5. Not available for proper shift 6. Other (Specify) 10